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HomeMy WebLinkAbout2018-472-E Finance - Pathways to Change outside agency agreementDocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2018, ( "Effective Date ") by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ( "County ") and Pathways to Change Inc., a not - for -profit corporation, located at 960 Corporate Drive Suite 408, Hillsborough, NC 27278 ( "Provider "). LtIVAN11►IM10AM WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Pathways to Change Inc. agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2018 to June 30, 2019. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $7,000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. The Provider shall be paid in four equal installments in the amount of $1,750. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Pathways to Change Inc.) Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. £ The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 — December 31; January 1 — March 31 and April 1 - June 30. Reports are due on January 11, April 12, and July 12 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default "), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Pathways to Change Inc.) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof, iii. Comprehensive Automobile Liability Insurance, including hired and non -owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION • Worker's Compensation • Commercial General Liability • Automobile Liability • Professional Liability MINIMUM REQUIRED COVERAGE Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee $1,000,000 Each Occurrence $2,000,000 Aggregate $500,000 Combined Single Limit $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Pathways to Change Inc.) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non - Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non - Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 14.25 per hour. To the extent possible, Orange County recommends that Pathways to Change Inc. provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Pathways to Change Inc.) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: Pathways to Change Inc. 960 Corporate Drive Suite 408 Hillsborough, NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147 - 86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. _,r _r.�_ For G oocu5igned�by:'.t -' PrOVd 2r �1R.UL.tG i�w i bit. 5.40C90 C2E2.4B402... For a ' oocusignedby: gunty Government 6 1tiAi' Rmiw''i(," 0637994B755E477... Bonnie Hammersley, County Manager (Pathways to Change Inc.) Orange County Outside Agency Performance Agreement Rev. 7118 8/21/2018 Date 8/23/2018 Date Page S of 9 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Pathways to Chan a Inc. Applicant Organization's Physical Address: 950 Car orate Drive Suite 408 Hillsborough, NC 27278 Applicant Organization's Mailing Address: 960 Corporate Drive, Suite 408, Hillsborough, NC 27278 Applicant Organization's Web Address: pathwaystochangenc.orq Executive Director: Kathryn Bauman Telephone Number: (919) 245 -3309 Tax 1D Number: 58- 2063924 E -Mail: kbaumangpathwaystochangenc.oLg bj Funding Request List all FY18 -19 ' Human Services (HS) Funding Being Requested For All Programs) and the Proposed Use of Funds (2 -3 lines or less) Program Carrboro Chapel Orange Total -HS Hill - HS County-HS Ex. Youth Afterschool Program l $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects 26 -week NG- Certified Partner Abuse Intervention $3,500 $6,000 $4,500 $14,000 (also called Batterer Intervention or Abuser Treatment 10 -week Anger Management Program $2,500 $3,000 $2,504 $8,400 Totals $6,000 $9,000 $7,000 $22,000 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant, Signature: Executi a blrector Signature.'�.�. Board Chairperson 1 23 zol Date _/p-3-10r8 Dat AGENCY INFORMATION 1/2312018 10:58:29 AM Page 8 of 32 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION dj DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NONDISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ Z a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ c) Current beneficiaries of the program for which funds are being requested? ❑ d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON - DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexUal orientation, gender identity /expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my Knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. R� Signature'."°' Executive Di or Signature.'b ' Board Chairperson ter' Date / /0;Z?- c C i Date AGENCY INFORMATION 1/22/2018 10:21:29 AM Page of 31 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (MonthlYear): 24 years, October 1993 b) Agency's Purposelmission (no more than a few sentences): Pathways to Change is a non - profit agency dedicated to enhancing public safety and quality of life by providing a variety of services to court- involved individuals and others desiring to address maladaptive or harmful patterns of behavior. Services are provided in an environment of respect, support, and accountability. c) Types of Services the Agency Provides (bullet format): • Partner Abuse Intervention — 26 -week program, also called Batterer Intervention or Abuser Treatment, is certified by the NC Council for Women (Domestic Violence Commission) and is appropriate for those convicted of domestic violence - related offenses • Ancler Management — 12 -week program appropriate for those convicted of non - domestic violence related offenses. • Strong Fathers -- strengths -based intervention for fathers overcoming cycles of family violence referred by child protective services or court personnel • Sentencin Plans — thorough assessment and report outlining a defendant's strengths and challenges, as well as recommended alternatives to active jail time, to be provided to sentencing judge d) Agency's History with Providing These Services: For more than 20 years, Pathways to Change has prepared risk -needs assessments and individualized treatment recommendations to individuals whose psycho - social challenges interfere with pro- social living. The agency began providing Partner Abuse Intervention and Anger Management in the spring of 2017. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director? Are there new initiatives ?) In the past year, Pathways to Change has changed both its name (from Behavioral Insights) and office location. Although it received state certification to provide Partner Abuse Intervention Programming in November of 2016, it did not begin providing these services or its Anger Management programming until spring of 2017. In the last year, it has also expanded to provide Anger Management and Partner Abuse Intervention to Durham and Chatham County residents. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full -Time Paid Positions: 0 Agency Information 1123/2018 11:18:32 AM Page 10 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION # of FTE - Paid Part -Time Positions. .5 # of Volunteers: 3 # of FTE - Volunteers -.15 g) Living Wage Does this agency pay permanent employees a minimum iyEn wage? (yes /No) Yes If yes, is this agency an orange CountL Living Wage Certified Employer? Yes If no, please explain. Agency Information 1/2312018 11:18:32 AM Page 9 9 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget L Is your agency currently receiving and/or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (YeslNo) Yes If yes, please list below: Include all programs that have funding requestslaward&4otals from Carrboro Chapel Hill and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as C BG and HOME. Program FY17 -18 FY18 -19 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro -- Other Ex. Total $15,000 $35,000 Carrboro Total Funding Partner Abuse Intervention $1,875 $1,875 1n -kind donation of space for meetings at Southern Human Services Buildin I *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants • Other Revenue • Expenditures a Compensation * Rent & Utilities Q Supplies & Equipment Agency Information 1/23/2018 11-18:32 AM Page 12 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION iv. o Travel & Training c Other Expenses Does your agency budget show a Surplus or Deficit? Balanced budget Is there a significant change? Yes /No No Please provide a brief explanation for Surplus or Deficit, and significant changes. What is your agency's fiscal year? (Example: July 1, 2016 through June 30, 2017) July 1 2018 — June 30, 2019 Agency Information 1/23/2018 1 1:18:32 AM Page 13 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER jk &W 6cj%PENCY APPLICATION Operating Budget for Entire Agency AGENCY TAME: Pathways to Change AGENCY REVENUE Private Donations Agency Generated Revenue (fees) Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue fund bal 16/17 Total Agency Revenue AGENCY EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses, Contract facilitators Total Agency Expenses SURPLUS /(DEFICIT) FOR PERIOD: FY 2018 -19 Agency Budget $ $ 43,533 27,242 $ $ 69,418 27,417 $ $ 58,517 27,417 -16% 0% $ 5,600 $ 10,301 $ 10,200 -1% $ 1,889 $ 2,400 $ 2,400 0% $ 189 $ 2,500 $ 2,500 0% $ 8,613 $ 26,800 $ 16,000 -40% $ 43,5$3 PMM 1 59,418 $ 585 517 A DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each Program Name: Partner Abuse Intervention Program Primary Contact and Title: Kathrvn Bauman Executive Director ram) Telephone Number: (919)145-3309 E -Mail: khauman @pathwaystochangenc.org a) Indicate the type of Human Service bleeds Priority, if program applicable: 0 Priority Area #1: safety -net services for disadvantaged residents ❑ Priority Area 2: education, mentorship, and afterschool programming for Youth facing a variety of challenges Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth FAdult Elderly Disabled Public Housing i Neighborhoods /Residents Affordable Housing Affordable Healthcare Education X X X X Family Resources Jobs /Jobs Training Food Transportation Other: Please specify c) Provide a buileted list of other agencies, if any, with which your agency coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. • Department of Social Services — Our staff provides presentations and liaises with DSS staff to enroll participants, monitor their progress, and support their case management needs • Courts /Probation /Parole — We liaise with court personnel and community corrections staff to receive referrals and provide /receive updates regarding participant progress • The Compass Center — We maintain a formal Memorandum of Understanding to ensure that victims of those participating in Partner Abuse Intervention Program are connected with therapeutic and supportive services PROGRAM INFORMATION 1123/2018 11:18:32 AM Page ! A o f 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS): Partner Abuse Intervention (PAI) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? Pathways to Change's Partner Abuse Intervention (PAC) program addresses the priority of improving the health of needy residents. This program helps participants recognize their abusive and controlling behavior in relationships and understand how this impacts their partners, other family members, and themselves. Participation therefore, improves the health of not only the participants, but also their current and future partners and family members. Per requirements of the NC Council for Women, Pathways staff members contact victims and/or current partners of all participants to communicate the limitations of the program and ensure that they are linked with victim services, typically through the Compass Center or another area victim service provider. Pathways' PAI program is informed primarily by the EMERGE model, which combines individual and group activities in order to best address the specific behavior patterns of each participant. e) Describe the community need or problem to be addressed in relation to the Chapel Mill Human Services Needs Assessment, Orange Count BOCC Goals and Priorities, Town of Chanel Hill Council Goals, Carrboro Board Priorities, or other community priorities. Our PAI program addresses the problem of domestic violence, which is closely related to several of the above - listed goals and priorities, Both the Town of Carrboro and the Orange County BOCC have prioritized enhancing and maintaining a high quality of life, including developing an "environment that promotes trust, mutual respect, acceptance, happiness, and well- being," In relationships characterized by violence and/or coercion, the happiness and well- being of all family members is jeopardized. One of the actions recommended in the 2012 Needs Assessment for Chapel Hill's HSAB was to fund efforts addressing "education and family resources." The majority of our PAI program participants arrive having no education surrounding how to engage in relationships characterized by fairness, equity, mutual respect, and negotiation. Almost all grew up in households where domestic violence was commonplace and have never questioned the dynamics they witnessed as children or society's pervasive normalization of toxic masculinity. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The primary beneficiaries of our program are its participants, who to -date have been court and social service - involved males between the ages of 22 and 60. These individuals are identified by court and social service personnel who refer them to our program via the secure online referral form found on our website, or by calling our office directly, PROGRAM INFORMATION 1/2312018 111:18:32 AM Page 1 5 of 3 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION When those convicted of domestic violence are referred to the PAI program, they are not the sole beneficiaries of the service. Obviously, our program is expected to improve the lives of our participants' current and future partners as well as their children and other family members. This occurs not only due to participants' improved treatment of their partners and children throughout the course of our programming, but also due to our contact with victims and partners to ensure their connection to victim service resources. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Pathways to Change's Executive Director, Kathryn Bauman, serves as program manager for its PAI program. Ms. Bauman is a Licensed Clinical Social Worker with 10 years of experience. She received 24 hours of training in the EMERGE Abuser Treatment Model in Arlington, MA in February of 2017 and has received, along with program facilitators, more than 10 hours of ongoing supervision from an expert in the Battering Intervention and Prevention Program field, Prior to her work at Pathways, Ms. Bauman ran the Strong Fathers Program, which also serves men overcoming cycles of family violence. Current PAI facilitators include Sam Clayborn, who was trained in the Duluth Model of Abuser Treatment in 2010 and has worked in social justice, domestic violence intervention and prevention, and substance abuse treatment since the late 1980s; Deanna Manley, who recently retired from the Durham Crisis Response Center after 10 years supporting domestic violence victims there; and Kaye Usry, a professor at Elon University with 3 years of experience facilitating PAI groups. Chris Dove, a very dedicated volunteer with extensive training on intimate partner violence and sexual assault, also facilitates our groups. As training for her volunteer responsibilities, Ms. Dove observed our contract facilitators for several months and participated in our twice- monthly consultation calls. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Because our PAI program operates on an "open group" format, which allows for rolling enrollment, participants can be referred and enrolled at any time during the program year. Outreach, recruitment, enrollment, and intervention delivery will occur simultaneously from July 1 — June 30th. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (280 words OR LESS) No other program in the greater Orange County area provides the kind of education and re- programming available to participants through Pathways' PAI program. Participants often arrive completely convicted of their beliefs regarding the role of men and women in relationships and feeling justified for their abusive and controlling behaviors. Over the course of our program's 26 weeks, they are exposed to ideas and opinions that challenge their belief systems and illustrate ways to increase equity and relationship satisfaction for Both partners as well as other family members. PROGRAM INFORMATION 1123/2018 11:18:32 AM wage 'i o f 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION j� Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If requested funding is not awarded, the Pathways Board of Directors will likely recommend maintaining the costs to participants at their current levels ($450 /participant). Because several stakeholders have cited these high costs as burdensome to participants, maintaining our costs at this level will likely prevent Pathways from increasing the numbers of citizens receiving our services. ky What percentage of your target population is low- moderate income? To -date, about 50% of our participants could be considered low- moderate income. This breakdown is consistent with our understanding that domestic violence cuts across all economic classes. 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) During each participant's intake assessment, he is provided with contact information for Pathways' Executive Director and encouraged to reach out to her with any concerns regarding the program or its facilitators. Upon completion of our programming, participants are asked to complete a brief, anonymous online satisfaction survey. m] Include any other pertinent information. According to the N. C. Domestic Violence Best Practices Guide for District Court Judges, Version 2012, "if the judge finds that a defendant "is responsible for acts of domestic violence" and there is an approved treatment program reasonably available, by statute s /he must order the offender to attend and complete the program, unless the court finds that it would not be in the best interests of justice. (G.S. 15A-1343(b)(1 Z)]." Despite the strong language quoted above, very few of the approximately 150 Assault on a Female convictions in Orange County in the past year resulted in the defendant being referred to our program. Various stakeholders have proposed different explanations for this lack of referrals, with some citing the high cost of our services as a barrier. (For this reason, we are proposing a reduction in cost for our Participants of $150 [from $450 to $300 for the 26 -week program].) Another explanation for the lack of referrals coming from the courts has been the relatively brief period of time that our services have been available. Before our programming began, no certified Batterer Intervention Program had been available in Orange County for several years. Pathways to Change undertook several efforts in 2017 to inform key stakeholders of its program's availability. These included meeting with individual judges; providing presentations to probation /parole, the Department of Social Services, the district attorneys, and the public defenders; and attending quarterly meetings of the Orange County Criminal Justice Advisory Council. PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 17 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Pro ram Information Partner Abuse Intervention n) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, rogram Target Population Qemograph Gender Male Female Total Ethnicity African - American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Total Of the above, how many Hispanic/Latino Of the above, how many non-Hispanic/Latino Total Age Geographic Location 0 -5 years 6 -18 years 19 -50 years 51 # years Total Actual Estimated Projected 2016 -17 2017 -18 2018 -19 3 44 44 0 0 40 3 44 44 2 16 16 2 40 40 3 44 44 1 28 28 3 44 44 5 1 5 3 44 44 1 4 4 2 40 40 3 44 44 Alarnance County Chatham County 1 11 Durham County 1 10 Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non- Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 1 11 11 3 35 35 9 9 3 44 44 Alarnance County Chatham County 1 11 Durham County 1 10 Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non- Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Total 1 3 1 44 44 PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 18 of 30 1 11 11 2 2 2 2 3 3 5 1 5 Total 1 3 1 44 44 PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 18 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement oy Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 9 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderlyldisabled residents.) • Program Goal should explain what the program is trying to achieve /accomplish. Goals are statements about what the program should accomplish, (i.e. Deliver 900 meals per day, Monday - Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 905 meals per day.) Work Statement Chart for Program Partner Abuse Intervention 9. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Conduct outreach to acquire referrals from community partners Will receive at least 65 referrals for Partner Abuse Intervention Will track number of referrals received from community partners 4 (Program only available for 2 mos. of previous year) 60 Next Year Projected Results 65 referrals 2. Program_ Activity Name Conduct assessment on referred individuals Program Goal Will conduct at least 52 assessments of referred individuals Performance Measures Will track number of assessments completed Previous Year Program Results 3 (Program only available for 2 mos. of previous year) Current Year Estimated Results 44 Next Year Projected Results 52 3. Program Activity Name 'Enroll assessed participants in program Program Goal Will enroll at least 48 participants (enrollment = attends 1 session) Performance Measures Will track number of participants enrolled Previous Year Program Results 3 (Program only available for 2 mos, of previous year) Current Year Estimated Results 40 Next Year Projected Results 48 4. Program Activity Name See participants through completion of program (26 weeks) Program Goal At least 44 participants will complete 26 -week program Performance Measures Will track number of participants finishing program (26 weeks) Previous Year Program Results N/A (Program only available for 2 mos. of previous year — not long enough for any participant to finish Current Year Estimated Results 17 (not all participants who enroll this year will be able to finish in this calendar year since program takes 26 weeks to complete) Next Year Projected Results 1 44 PROGRAM INFORMATION 1/2312018 11:18:32 AM Page 19 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION P) Program Budget 1. Submit your program budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template), Program Budgets are required to define Budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding Mere) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBGIHOMEIetc.) • Private Foundation Grants • Other Revenue Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. Expenses listed in the "Other" category include compensation for contract facilitators to plan and facilitate sessions as well as engage in twice- monthly supervision phone calls with a Batterer Intervention Program consultant to ensure high duality of service. 3. This program budget represents what percent of the agency budget's 35% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2016 -17 Estimated 2017 -18 1 Projected 2018 -19 Total Cost of Program ` $10,883 $18,990 $20,760 Total ## of Individuals 3 44 44 Cost Per Individual $3627 $431 $472 PROGRAM INFORMATION 1123/2018 11:18-32 AM Page 20 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM NAME PROGRAM REVENUE Private Donations Program Budget Operating Budget for Program Partner Abuse Intervention Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Garrboro Human Services - Town of Chapel Full Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGfHOMEIetc.) Private Foundation Grants Other Revenue fund bal. Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: (Contract facilitators) Total Program Expenses SURPLUSI(DEFICIT) FOR PERIOD: FY 2018 -19 Program Budget Is (0)1$ 1 is - I - 1007/. Actual Estimated Projected Percent 2016 -17 2017 -18 2018 -19 Chan e $ - $ - $ - 0 $ 500 $ 13,140 $ 6,760 -49 %a $ 1,250 $ 1,750 $ 3,500 100% $ $ - $ - 0 3,750 $ 1,750.-$ 6,000 243% $ - $ - $ - 0 $ 2,000 $ 2,350 $ 4,500 91% $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - S - $ - 0 $ - $ - $ - o $ - $ - $ - 0 $ 3,383 $ - $ - 0 $ 1 0,883 $ 18,990 $ 20,760 9% $ 6,811 $ 6,854 $ 9,585 40% $ 1,400 S 2,575 $ 2,575 0% $ 472 $ 600 $ 6o0 0 % $ 47 $ 2,600 $ 2,500 0 % $ 2,153 $ 6,460 $ 5,500 -15% $ 10,883--[—$ 18,930 $ 20,760 3 °�0 Is (0)1$ 1 is - I - 1007/. DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Anger Mana ement Program Primary Contact and Title: Kathryn Bauman, Executive Director Telephone Number: 919 245 -33fl9 E- Mail: kbau-nana_oathwaystnrhangenc.org a) Indicate the type of Human Service Needs Priority, if program applicable: 0 Priority Area #1: safety -net services for disadvantaged residents El Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges Z Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Ei Affordable Housing Affordable Healthcare Education X X Famil Resources Jobs /Jobs Training Food Transportation Other: Please specify deify Disabled Public Housing Neighborhoods/Residents X IX c) Provide a bulleted list of other agencies, if any, with which your agency coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. Department of Social Services — Our staff provides presentations and liaises with DSS staff to enroll participants, monitor their progress, and support their case management needs o Courts /Probation /Parole We liaise with court personnel and community corrections staff to receive referrals and provide /receive updates regarding participant progress PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 21 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Anger Management Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? Like our Partner Abuse Intervention program, our Anger Management (AM) program, addresses the priorities of education and improving the health of residents. Those referred to our program have struggled to find pro - social ways to manage conflict in their communities. Their health and the health of other citizens is adversely impacted by their lack of knowledge and skill surrounding healthy conflict resolution and emotion regulation. Pathways' AM program consists of 10 weekly sessions that explore the origins and purpose of anger, how to monitor intensity of angry feelings, immediate strategies for managing anger expression, how distorted beliefs and thoughts can fuel anger, healthy communication including assertiveness and active listening, stress management and self -care, establishing and maintaining healthy boundaries, and debriefing/repair after an argument. Participants can complete sessions in a group or individually with a facilitator. Although individual sessions are more costly for participants, they allow for greater flexibility in scheduling. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Oran e Count SOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council /Board Goa)s). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program, According to staff in the Orange County District Attorney's Office, approximately 100 -150 cases brought before the courts per year concern disputes between neighbors, landlords and tenants, motorists, and other unrelated acquaintances in the community. When disputes between these parties involve criminal behavior (damage to property, simple assault, etc), it is likely that they impact the health, safety, and well -being of involved citizens as well as others in their periphery. (See Orange County BOCC Goal 1). Despite their often "minor" nature, crimes like these can be costly to perpetrators and victims, sometimes jeopardizing their ability to remain in public housing or access other social safety net programs. Long -term, uncontrolled anger can also contribute to health problems, such as heart disease and hypertension. Thus, the problem of inappropriate anger expression intersects with many other town and county priorities, including health and affordable housing and family resources. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Our target population for the AM program includes any adult who is facing or has been convicted of charges stemming from the inappropriate expression of anger, including simple assault, destruction of property, or other minor crimes. This program is not appropriate for individuals whose crimes are part of a pattern of PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 22 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION abusive or controlling behavior in a relationship. For those individuals, our Partner Abuse Intervention program would be the appropriate referral. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Pathways' Executive Director Kathryn Bauman acts as program manager for the Anger Management program. She is a clinical social worker with 10 years of experience working with adults and children with various emotion regulation difficulties. Together with a UNC School of Social Work intern, she created the current version of Pathways' Anger Management curriculum, using several different curricula and elements of evidence -based therapeutic interventions like Cognitive Behavioral Therapy and Dialectical Behavioral Therapy. Ms. Bauman also facilitates Anger Management groups and individual sessions. Samuel Clayborn, a very experienced facilitator with more than 35 years of work in various social and criminal justice arenas, also facilitates Anger Management groups. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. This year, we plan to run our Anger Management program on a closed -group model, This means that all participants in a particular group will start and end sessions on the same date. In order to accommodate participants as quickly as Possible, we will plan to start a new group every two months. This means we will start groups at the beginning of July, September, November, January, March, and May. Recruitment and enrollment will be ongoing, with enrollment of the first group occurring before the beginning of the 2018119 fiscal year. 0 Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) District Court Judges in Orange County often mandate anger management Programming in landlord - tenant disputes and various other types of neighbor and consumer disputes. Without this programming, those who commit these crimes never learn healthy and pro - social ways to express anger and manage conflict and are likely to reengage in criminal behavior when faced again with the typical stressors of community life. Reducing recidivism serves, not only to protect the health and well -being of offenders and victims, but also to facilitate intact family time, thereby reducing the burden on over - strained government support systems. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. This year's proposed fee for participation in our Anger Management program represents a reduction of $115. (From $315 to $200.) This is in response to stakeholder concerns that our participant fees were too costly and represented a barrier to participation. If requested funding is not awarded, the Pathways Board of Directors will likely opt to maintain fees at their current level, thereby limiting the numbers of participants who can afford the programming. k) What percentage of your target population is low - moderate income? PROGRAM INFORMATION 1123/2018 11:18:32 AM Page 23 of 3 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION To -date, approximately 50% of our participants have been low- moderate income. if we are able to reduce our participant fees as proposed, this number is likely to increase. Ij What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) All participants are asked to complete a brief, anonymous online satisfaction survey following completion of the program. m) Include any other pertinent information. PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 24 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Pro ram Information: Anger Management nj Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected Gender 2Q16 -17 2017 -18 2018 -19 - Male 3 14 21 Female 1 6 g Ethnicity Total 4 20 30 African- American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Total Of the above, how many Hispanic/Latino Of the above, how many non- Hispanic/Latino Total Age Geographic Location 0 -5 years 6 -18 years 19 -50 years 51+ years Total 4 14 21 4 18 27 4 20 30 1 6 g 0 20 0 2 3 4 20 30 Alarnance County Chatham County Durham County 1 10 15 Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non- Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 2 3 4 18 27 4 20 30 Alarnance County Chatham County Durham County 1 10 15 Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non- Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 2 2 3 4 20 30 1 4 6 0 20 0 Alarnance County Chatham County Durham County 1 10 15 Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non- Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Total 4 20 30 PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 25 of 30 2 2 3 1 4 6 2 3 2 3 Total 4 20 30 PROGRAM INFORMATION 1/23/2018 11:18:32 AM Page 25 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement o] Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) if this is a new program, you will only document the Projected information. Every program is required to have AT LEAST 7 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time - bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderlyldisabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i e. Deliver 700 meals per day, Monday - Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. if goals were not met, please explain. (i.e. Delivered an average of 705 meals per day.) Work Statement Chart for program Anger Management 5. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 6. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 7. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results Conduct outreach to acquire referrals from community partners Will receive at least 57 referrals for Anger Management Will track number of referrals received from community partners 4 26 57 referrals Conduct assessment on referred individuals Will conduct at least 52 assessments of referred individuals Will track number of assessments completed 4 22 46 Enroll assessed participants in program Will enroll at least 37 participants (enrollment aattends 1 session Will track number of participants enrolled 4 18 37 8. Program Activity Name See participants through completion of program (10 weeks) Program Goal At least 30 participants will complete 10 -week program Performance Measures Will track number of participants finishing program (10 weeks) Previous Year Program Results 3 Current Year Estimated Results 15 (not all participants who enroll this year will be able to finish in this calendar year since program takes 26 weeks to complete Next Year Projected Results 3(l PROGRAM INFORMATION 1/23/2018 11:18.32 AM Page 26 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION p) Program Budget 5. Submit your program budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, in the same format; as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United way • State Government • Federal Government (CDBGIHOMEfetc.) • Private Foundation Grants Other Revenue Expenditures a Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses 6. Program Budget Detail Provide description of "other" budget items, not defined. 7. This program budget represents what percent of the agency budget? 224% 8. COST PER INDIVIDUAL This Cast per Individual must reflect the total program budget divided by the total number of program individuals in this application. PROGRAM INFORMATION 1/2312018 11:18:32 AM Page 27 of 30 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program $9022 $9775 $14000 Total # of Individuals 4 20 30 Cost Per Individual $2225 $489 $466 PROGRAM INFORMATION 1/2312018 11:18:32 AM Page 27 of 30 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Anger Management PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue fund bal. Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: (Contract facilitators) Total Program. Expenses $ $ Actual 2016 -17 - 376 $ $ Estimated 2017 -18 2,604 S Projected 2018 -19 6,000 Percent Change 0 131% $ $ 1,250 - $ $ 1,750 - $ $ 2,500 _ 43% 0 5 3,750 $ 3,075 $ 3,000 -2% $ $ - $ - 0 $ 1;_I A. 2,350 $ 2,500 F °fo $ - $ - 0 0 $ - $ - $ - a $ - $ - $ - 0 $ 2,646 Is _ 0 1$ $ 9,022 5,400 $ $ 9,775 4,950 $ $ 14,000 6,385 43% 29% $ 1,400 $ 2,575 $ 2,575 0% $ 120 $ 120 $ 120 0% $ 102 $ 120 $ 120 0 % $ 2,000 $ 2,000 $ 4,800 140 %0 $ 9,022 $ 5,775 $ 14,000 43% SURPLUS/ {DEFICIT} FOR PERIOD: 1 $ - 1 $ s $ _ 0 DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 EXHIBIT 1111311 Scope of Services — FY 2018 -19 Outside Agency Performance Agreement Agency Name: Pathways to Change Program Name: Partner Abuse Intervention and Anger Management Funding Award: $7,000.00 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. Pathways to Change will enroll participants in the following programs during fiscal year 20118 -19. - 12 -Week ANGER MANAGEMENT PROGRAM: Our Emotional Intelligence & Anger Management program offers participants an opportunity to explore triggers for their anger, discover the dynamics of social and emotional competence, and replace unhealthy behaviors and communication styles with respectful, controlled and assertive communication. - 26 -Week PARTNER ABUSE INTERVENTION PROGRAM: Our Partner Abuse Intervention program meets North Carolina requirements for Batterer Intervention or Abuser Treatment. Participation in a program like this may be court- ordered after an individual is convicted of a domestic violence crime. Others may be referred by social services, their church, or themselves. This program aims to help participants • Recognize and acknowledge harmful behavior they've practiced in relationships • Understand the impact of their behavior on their partners, their families, and themselves • Develop empathy for their partners and begin to make amends for harm they've caused • Learn how ti oocusiyned by: )ectfully in relationships a 4roider's VUA.tL 6Gt.. E �eJc}uti Di rector Certified by: 5.4..... E2.46402... Title: VL4 � "L Date: Signature) DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons /units served within Orange County,, only (all Towns and municipalities). If you use percentages, you must also 2rovide the total number of particiVants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results PARTNER ABUSE INTERVENTION: Track referrals to Pathways to Change vis -A -vis online 65 referrals referral system, new volunteer court liaison for abuser accountability program (in court for PAI appearances), presentations to various law enforcement agencies; and telephone referrals, etc. All referrals will be maintained in Pathways database which contains referrer name, contact, and demographic information about person being referred. PARTNER ABUSE INTERVENTION: Pathways will conduct 52 assessments on those 52 referred to the PAI program. These are in person interviews where the potential participant is assessments engaged in an intensive one -hour interview, including lethality assessment, etc. This will be conducted tracked via intake forms that are uploaded to Pathways Team Drive which is a Google -based platform. PARTNER ABUSE INTERVENTION: Seventeen (17) participants will successfully complete 17 Pathways 26 -week Partner Abuse Intervention Program. Attendance is tracked by facilitators on successful a Team Drive that is a Google -based platform. Cases are normally dismissed after completion of PAI the program, Because the course runs 26 -weeks it is unlikely that all of those referred, assessed completions. and enrolled will have completed the course at the conclusion of the 2018 -19 fiscal year. ANGER MANAGEMENT: Track referrals to Pathways to Change vis -a -vis online referral 57 referrals system, new volunteer court liaison for abuser accountability program (in court appearances), to Anger presentations to various law enforcement agencies; marketing via MailChimp automated software Management marketing software platform, and telephone referrals, etc. All referrals will be maintained in Pathways database which contains referrer name, contact, and demographic information about person being referred. ANGER MANAGEMENT: Pathways will conduct forty -six (46) assessments on those referred 46 to the Anger Management program. These are in person interviews where the potential assessments participant is engaged in an intensive one -hour interview to best assess needs. This will be conducted tracked via intake forms that are uploaded to Pathways Team Drive which is a Google -based latform. ANGER MANAGEMENT• Fifteen (15) participants will successfully complete Pathways 12- 15 week Anger Management Program. Attendance is tracked by facilitators on a Team Drive that is successful a Google -based platform. Cases are nonrally dismissed after completion of the program. Anger Management com letions �Q [� -Ire? c` Certified by: Docu5iynedbY: ltle: ate: Pro Qt Lwt, 16kti 8/21/2018 Executive Director 5.40C90 C2E2.4B402... DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 ATTACHMENT "A" Orange County Certifications — FY 2018 -19 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Docu5igned by: Q1rt.1n.tG Certified by 5.goC9oc2E2.4B402... (Provider's Signature) Executive Director Title: Date: 8/21/2018 (Pathways to Change Inc) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: 74839431- 9216- 429F- BFA4- 2AC6473BD9D3 �•�•``•� CERTIFICATE OF LIABILITY INSURANCE GATE (MM/DDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE. HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING, INSURER(S),, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the Policy( i09) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain Policies may require an endorsement. A Statement on this certificate does not confer rights to the certificate holder in lieu of such endorsee nt(a ). PRODUCER Business Insurers of Carolinas 800 Eastowne Drive, Suite 208 PO Box 2536 Chapel hill NC 27515 -2536 INSURED Pathways to Change 960 Corporate Drive Suite 408 Hillsborough NC 27278 NAhIE: L Amber Curiae PHONE (919) 968 -4611 FAx {A(g, Ma. Eat};_ . —(A/C , "y (919) 968 -8991 E-MAIL ADDRESS; acurlee[ business— insurers . com INSURERS) AFFORDING COVE RAGE NAIC # IINSURER AAmerican Casualty Company of 20427 INSURERB:Lloyda of London 00432 INSURER C: i INSLIRER D: NSURER E �uvtrc�,C�a =S CERTIFICATE NUMBER,CL1761918902— - REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TR ADDLSUER., . -TR : TYPE OF INSURANCE POI_ €CY NUMBER POLICY EFF POLICY EXP XCOMMERCIALG£NERAL LIASILITY MMI❑ YYYY IDDfYYYY LIMITS (:ACH OCCURRENCE S 1,004,000 p+ CLANS-MADE OCCUR DAMAGE TO RENTED i GEN'L AGGREGATE LIMIT APPLIES PER x PRO- POLICY — „ JECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS �_ y AUTOS HIRED AUTOS NON -OWNED -- AUTOS X 6021140912 UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS-MADE DED RETNTK)NS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY ?ROF+31E:'CRIPARTNERIEMECUTiVE OFr''CE.R1VF,MI3FR EXCLUDED? NIA (Mandatory in NH) If yes desclihe url.dw 13 FrOf6s$lcinal Liability 14PL148440017 7/1/2017 7/1/2018 PREMISES;E3cim mrcej S ME EXP "Any one perwni S PERSONAL d ADV INJURY S GENERAL AGCREGATF S PRODUCTS - COMP,"OP AGO S BAIL S C N D S—IN i E LINII S BODILY INJURY spur per@CNt; S BODILY INJURY ,Par awoenli S PROPERTY DAMAGE S ;Per a=dent, S EACH OCCURRENCE 5 AGGREGATE, S S E L EACH ACCIOENI S E.L. DISEASE - EA EMPLOYEE, $ E L. DISEASE -POLICY LIMIT S 8/29/2017 9/25/2019 LIMIT AGGREGATE DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 141, Additional Remarks Schedule, may be attached if more space is required) Orange County is an additional insured with respect to general liability per written contract. CERTIFICATE HOLDER CANCELLATION 900,000 10,000 1,000,000 2,000,000 2,000,000 1,D00 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 9E CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 S. Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8161 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Amber Cur Yee /AMBER 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 2� .W7